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The Healthy Heart Handbook for Women

Major Risk Factors for Heart Disease

High Blood Cholesterol
High blood cholesterol is another major risk factor for heart disease that you can do something about. The higher your blood cholesterol level, the greater your risk for developing heart disease or having a heart attack. To prevent these disorders, all women should make a serious effort to keep their cholesterol at healthy levels.

If you already have heart disease, it is particularly important to lower an elevated blood cholesterol level to reduce your high risk for a heart attack. Women with diabetes also are at especially high risk for a heart attack. If you have diabetes, you will need to take steps to keep both your cholesterol and your diabetes under control.

Although young women tend to have lower cholesterol levels than young men, between the ages of 45 and 55, women's levels begin to rise higher than men's. After age 55, this "cholesterol gap" between women and men becomes still wider. Although women's overall risk of heart disease at older ages continues to be somewhat lower than that of men, the higher a woman's blood cholesterol level, the greater her chances of developing heart disease.

Cholesterol and Your Heart
The body needs cholesterol to function normally. However, your body makes all the cholesterol it needs. Over a period of years, extra cholesterol and fat circulating in the blood build up in the walls of the arteries that supply blood to the heart. This buildup, called plaque, makes the arteries narrower and narrower. As a result, less blood gets to the heart. Blood carries oxygen to the heart. If not enough oxygen-rich blood can reach your heart, you may suffer chest pain. If the blood supply to a portion of the heart is completely cut off, the result is a heart attack.

Cholesterol travels in the blood in packages called lipoproteins. LDL carries most of the cholesterol in the blood. Cholesterol packaged in LDL is often called "bad" cholesterol, because too much LDL in the blood can lead to cholesterol buildup and blockage in the arteries.

Another type of cholesterol is HDL, known as "good" cholesterol. That's because HDL helps remove cholesterol from the body, preventing it from building up in the arteries.

Getting Tested
High blood cholesterol itself does not cause symptoms, so if your cholesterol level is too high, you may not be aware of it. That's why it's important to get your cholesterol levels checked regularly. Starting at age 20, all women should have their cholesterol levels checked by means of a blood test called a "fasting lipoprotein profile." Be sure to ask for the test results, so you will know whether you need to lower your cholesterol. Ask your doctor how soon you should be retested.

Total cholesterol is a measure of the cholesterol in all of your lipoproteins, including the "bad" cholesterol in LDL and the "good" cholesterol in HDL. An LDL level below 100 mg/dL* is considered "optimal," or ideal. However, not every woman needs to aim for so low a level. As you can see on the next page, there are four other categories of LDL level. The higher your LDL number, the higher your risk of heart disease. Knowing your LDL number is especially important because it will determine the kind of treatment you may need.

Your lipoprotein profile test will also measure levels of triglycerides, another fatty substance in the blood. (See "What Are Triglycerides?".)

* Cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (dL) of blood.

What's Your Number?

Blood Cholesterol Levels and Heart Disease Risk

Total Cholesterol Level

Category

Less than 200 mg/dL

Desirable

200-239 mg/dL

Borderline high

240 mg/dL and above

High

LDL Cholesterol Level

Category

Less than 100mg/dL

Optimal (ideal)

100-129 mg/dL

Near optimal/above optimal

130-159 mg/dL

Borderline high

160-189 mg/dL

High

190 mg/dL and above

Very high

HDL Cholesterol Level
An HDL cholesterol level of less than 40 mg/dL is a major risk factor for heart disease. An HDL level of 60 mg/dL or higher is somewhat protective.

Heart Disease Risk and Your LDL Goal
In general, the higher your LDL level and the more other risk factors you have, the greater your chances of developing heart disease or having a heart attack. The higher your risk, the lower your LDL goal level will be. Here is how to determine your LDL goal:

Step 1: Count your risk factors. Below are risk factors for heart disease that will affect your LDL goal. Check to see how many of the following risk factors* you have:

Cigarette smoking

High blood pressure (140/90 mmHg or higher, or if you are on blood pressure medication)

Low HDL cholesterol (less than 40 mg/dL)†

Family history of early heart disease (your father or brother before age 55, or your mother or sister before age 65)

Age (55 or older)

Step 2: Find Out Your Risk Score. If you have two or more risk factors in Step 1, you will need to figure out your "risk score." This score will show your chances of having a heart attack in the next 10 years. To find out your risk score, see "How To Estimate Your Risk".

* Diabetes is not on the list because a person with diabetes is already considered to be at high risk for a heart attack—at the same level of risk as someone who has heart disease. Also, even though overweight and physical inactivity are not on this list of risk factors, they are conditions that raise your risk for heart disease and need to be corrected.

Step 3: Find Out Your Risk Category. Use your umber of risk factors, risk score, and medical history to find out your history to find out your category of risk for heart disease or heart attack. Use the table below:

If You Have

Your Category Is

Heart disease, diabetes, or a risk score of more than 20 percent

High Risk

2 or more risk factors and a risk score of 10 to 20 percent

Next Highest Risk

2 or more risk factors and a risk score of less than 10 percent

Moderate Risk

0 to 1 risk factor

Low-to-Moderate Risk

What Are Triglycerides
Triglycerides are another type of fat found in the blood and in food. Triglycerides are produced in the liver. When you drink alcohol or take in more calories than your body needs, your liver produces more triglycerides. Triglyceride levels that are borderline high(150-199 mg/dL) or high (200-499 mg/dL) are signals of an increased risk for heart disease. To reduce blood triglyceride levels, it is important to control your weight, get more physical activity, quit smoking, and avoid alcohol. You should also follow an eating plan that is not too high in carbohydrates (less than 60 percent of calories) and is low in saturated fat, trans fat, and cholesterol. Sometimes, medication is also needed.

"No one, least of all me, was ever really concerned about my heart health because I was a young, thin female, who did not smoke. After my heart attack, I had to face my own mortality. It was a life-altering event for my entire family."

— Erin

A Special Type of Risk
Some women have a group of risk factors known as "metabolic syndrome," which is usually caused by overweight or obesity and by not getting enough physical activity. This cluster of risk factors increases your risk of heart disease and diabetes, regardless of your LDL cholesterol level. Women have metabolic syndrome if they have three or more of the following conditions:

A waist measurement of 35 inches or more

Triglycerides of 150 mg/dL or more

An HDL level of less than 50 mg/dL

Blood pressure of 130/85 mmHg or more (either number counts)

Blood sugar of 100 mg/dL or more

If you have metabolic syndrome, you should calculate your risk score and risk category as indicated in Steps 2 and 3 on the previous page. You should make a particularly strong effort to reach and maintain your LDL goal. You should emphasize weight control and physical activity to correct the risk factors of the metabolic syndrome.

Recent studies have added to the evidence suggesting that for people with heart disease, lower LDL cholesterol is better. Because these studies show a direct relationship between lower LDL cholesterol and reduced risk for heart attack, it is now reasonable for doctors to set the LDL treatment goal for heart disease patients at less than 70 mg/dL—well below the recommended level of less than 100 mg/dL. Doctors may also use more intensive cholesterol-lowering treatment to help patients reach this goal.

If you have heart disease, work with your doctor to lower your LDL cholesterol as much as possible. But even if you can't lower your LDL cholesterol to less than 70 mg/dL because of a high starting level, lowering your LDL cholesterol to less than 100 mg/dL will still greatly reduce your risk.

How To Lower Your LDL
There are two main ways to lower your LDL cholesterol—through lifestyle changes alone, or though medication combined with lifestyle changes. Depending on your risk category, the use of these treatments will differ. Because of the recent studies that showed the benefit of more intensive cholesterol lowering, physicians have the option to start cholesterol medication—in addition to lifestyle therapy—at lower LDL levels than previously recommended for high-risk patients. For information on the updated treatment options and the best treatment plan for your risk category, see the fact sheet, "High Blood Cholesterol: What You Need To Know," available on the NHLBI Web site or from the NHLBI Health Information Center. (See "To Learn More".)

Lifestyle Changes. One important treatment approach is called the TLC Program. TLC stands for "Therapeutic Lifestyle Changes," a three-part treatment that uses diet, physical activity, and weight management. Every woman who needs to lower her LDL cholesterol should use the TLC Program. (For more on the TLC approach, see "Eat for Health".) Maintaining a healthy weight and getting regular physical activity are especially important for women who have metabolic syndrome.

Medication. If your LDL level stays too high even after making lifestyle changes, you may need to take medicine. If you need medication, be sure to use it along with the TLC approach. This will keep the dose of medicine as low as possible and lower your risk in other ways as well. You will also need to control all of your other heart disease risk factors, including high blood pressure, diabetes, and smoking.

CHOLESTEROL-LOWERING MEDICINES
As part of your cholesterol-lowering treatment plan, your doctor may recommend medication. The most commonly used medicines are listed below.

Statins. These are the most commonly prescribed drugs for people who need a cholesterol-lowering medicine. They lower LDL levels more than other types of drugs—about 20 to 55 percent. They also moderately lower triglycerides and raise HDL. Side effects are usually mild, although liver and muscle problems may occur rarely. If you experience muscle aches or weakness, you should contact your doctor promptly.

Ezetimibe. This is the first in a new class of cholesterol-lowering drugs that interferes with the absorption of cholesterol in the intestine. Ezetimbe lowers LDL by about 18 to 25 percent. It can be used alone or in combination with a statin to get more lowering of LDL. Side effects may include back and joint pain.

Bile acid resins. These medications lower LDL cholesterol by about 15 to 30 percent. Bile acid resins are often prescribed along with a statin to further decrease LDL cholesterol levels. Side effects may include constipation, bloating, nausea, and gas. However, long-term use of these medicines is considered safe.

Niacin. Niacin, or nicotinic acid, lowers total cholesterol, LDL cholesterol, and triglyceride levels, while also raising HDL cholesterol. It reduces LDL levels by about 5 to 15 percent, and up to 25 percent in some patients. Although niacin is available without a prescription, it is important to use it only under a doctor's care because of possibly serious side effects. In some people, it may worsen peptic ulcers or cause liver problems, gout, or high blood sugar.

Fibrates. These drugs can reduce triglyceride levels by 20 to 50 percent, while increasing HDL cholesterol by 10 to 15 percent. Fibrates are not very effective for lowering LDL cholesterol. The drugs can increase the chances of developing gallstones and heighten the effects of blood-thinning drugs.

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